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October 16, 2009
Reforming the 'doctorless' health system
It’s old news by now that the Senate Finance Committee has approved legislation that would attempt to reform our health care system. The major features of the revised Baucus bill would include mandatory health insurance for nearly all Americans, taxes on “Cadillac” insurance plans, the creation of non-profit insurance cooperatives, special taxes on drug/ medical device makers as well as insurance companies, and elimination of “pre-existing condition” exclusions.
Republicans promise to make the bill’s passage through the Senate difficult, and hardline Democrats still have their sights set on a public insurance option. We can continue, therefore, to expect the negotiations to play out with the subtlety and finesse of a prize fight.
The vested lobby groups are certainly swinging harder than ever. The Washington Post revealed that the health sector has been spending money at a rate of $1.5 million a day (yes, a day) in an attempt to influence health care reform legislation. Really, who turns enough profit to invest that sort of money in politics? Apparently the biggest spenders were drug manufacturers, hospitals, and insurance groups. And if $1.5 million a day weren’t enough to buy political favor, the insurance industry also launched an ambush attack the day before the vote by releasing a report that suggested that reform could potentially increase insurance premiums. The Democrats labelled the attack scaremongering, and Obama said it confirmed that the legislation was heading in the right direction.
There’s a lot of talk about the vested interests of pharmaceutical manufacturers and insurance companies (rightly so), but what about the system’s users and providers? Where have the doctors and patients gone? Maybe I’m self-interested because I am a doctor and I work with patients, but I’d like know—while congressional committees are debating over insurance exchanges and gold-plated policies—where are the doctors and patients who collaborate on treatment plans?
Dr. Arnold Relman, writing in the New England Journal of Medicine, makes the obvious, but somehow overlooked, point that it’s doctors that make most decisions about the use of medical resources—the same doctors that have a strong financial incentive to maximize elective services and utilize new, expensive technology. This begs the question: how will the proposed legislation control inflationary health care costs as long as doctors are incentivized to use more services and resources? The existing system has encouraged a creeping entrepreneurial ethic into medicine. Physicians who work in hospital systems are rewarded for doing procedures and tests, and the yield from Medicare/Medicaid is comparatively higher for inpatient vs. Outpatient care. In many instances these programs don’t pay for outpatient wellness visits—only sick ones. Meanwhile, primary care providers may see 41 patients a day and receive little to no reimbursement for time spent educating patients about preventative health care. Likewise, some patients are happy to report to the emergency department, rather than a primary care provider, with an earache or head lice. (Yes, I’ve personally witnessed that). What will incentivize those people to purchase health insurance? A $750 annual penalty, I don’t think so (and then there is the “hardship” clause that would exempt people who are likely to be using the emergency department as primary care).
These are not just administrative issues; this is about the health care culture in our country. Surely cultural change must be pivotal in any real overhaul of our health care system, so shouldn’t the vested interests of doctors and patients—not only drug and insurance companies—be central to the debate?
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Further reading:
Eggen, D 2009 At $1.5 million a day, health sector lobbying far outpaces oil and gas, The Washington Post.
Relman, AD 2009 Doctors as the key to health care reform, New England Journal of Medicine, 24 September, vol.361, no. 13.
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